AFRICAN DEVELOPMENT FUND Language : English Original : French BURKINA FASO HEALTH CARE DEVELOPMENT SUPPORT PROJECT (CENTRE-EAST AND NORTH REGIONS) APPRAISAL REPORT NB: This document contains errata or corrigenda (see Annexes) SOCIAL DEVELOPMENT DEPARTMENT OCSD CENTRAL AND WEST REGIONS MARCH 2005 SCCD: G. G.
TABLE OF CONTENTS PROJECT INFORMATION SHEET, CURRENCIES AND MEASURES, LIST OF TABLES, LIST OF ANNEXES, LIST OF ABBREVIATIONS, BASIC DATA, LOGICAL FRAMEWORK OF PROJECT, EXECUTIVE SUMMARY (i) - (xiii) 1. ORIGIN AND HISTORY OF THE PROJECT...1 2. THE HEALTH SECTOR...2 2.1 Health status...2 2.2 National health policy...3 2.3 Organization and functioning of the sector...4 2.4 Human resources...6 2.5 Health sector financing...7 2.6 Donor intervention...7 2.7 Sector constraints...9 3. PROJECT AREAS...10 3.1 Availability of health facilities...10 3.2 Utilization of health services...12 3.3 Communicable and non-communicable diseases...14 3.4 Health system management...16 4. THE PROJECT...16 4.1 Design and rationale...16 4.2 Project area and beneficiaries...18 4.3 Strategic context...19 4.4 Project objectives...20 4.5 Description of project outputs...20 4.6 Environmental impact...26 4.7 Project costs...26 4.8 Financing sources and expenditure schedule...27 5. PROJECT IMPLEMENTATION...29 5.1. Executing agency...29 5.2. Institutional arrangements...30 5.3. Implementation and supervision schedules...31 5.4. Procurement arrangements...31 5.5 Disbursement arrangements...35 5.6 Monitoring and evaluation...36 5.7 Financial reporting...37 5.8 Aid coordination...38
6. PROJECT SUSTAINABILITY AND RISKS...39 6.1 Recurrent costs...39 6.2 Project sustainability...39 6.3 Critical risks and mitigative measures...40 7. PROJECT BENEFITS...41 7.1 Economic impact...41 7.2 Social impact...41 7.3 Impact on women...42 8. CONCLUSIONS AND RECOMMENDATIONS...42 8.1 Conclusions...42 8.2 Recommendations...43 This report was prepared following the appraisal mission to Burkina Faso from 24 January to 9 February 2005 by Mrs. Raymonde Y. COFFI (Architect OCSD.2), a Health Expert Consultant and an Architect Consultant. Enquiries should be referred to Mr. N. SAFIR, Acting Director, OCSD (Extension 2141) and E. J. PORGO, Division Manager, OCSD.2 (Extension 2173).
i AFRICAN DEVELOPMENT FUND 01 P.O. Box 1387 ABIDJAN 01 Phone. : 20-20-44-44 - Fax : 20-20-40-99 HEADQUARTERS TEMPORARY RELOCATION AGENCY 01 P.O. Box 1387 Abidjan 01 P. O. Box 323, 1002 Tunis Belvédère Côte d Ivoire Tunisia Tel : (225) 20 20 44 44 Tel : (216) 71 33 35 11 Fax : (225) 20 20 40 99 Fax : (216) 71 35 19 33 PROJECT INFORMATION SHEET Date: March 2005 The information given below is intended to provide some guidance to prospective suppliers, contractors, consultants and all persons interested in the procurement of goods and services for projects approved by the Board of Directors of the Bank Group. More details should be obtained from the executing agency of the Borrower. 1. COUNTRY : Burkina Faso 2. NAME OF PROJECT : Health Care development support project Centre-East and North Regions. 3. LOCATION : Centre-East and North Regions and countrywide for health units and regulatory support. 4. BORROWER : the Government of Burkina Faso 5. EXECUTING AGENCY : Project Implementation Unit 03 P. O. Box 7009 Ouagadougou 03 Fax: (226) 50 36 24 64 Tel: (226) 50 32 41 63 6. PROJECT DESCRIPTION: The project which will span 5 (five) years comprises the following four components and expenditure categories: I. Improved access to quality health care: Services, Works, Goods, Operation. II. Disease control: Services, Goods, Operation. III. Capacity building: Services, Goods, Operation. IV. Project management: Services, Goods, Operation. 7. TOTAL PROJECT COST: i) cost in foreign currency : UA 19.22 million ii) cost in local currency : UA 8.78 million iii) total cost : UA 28.00 million
ii 8. BANK GROUP FINANCING Loan : UA 19.00 million Grant : UA 6.00 million 9. OTHER FINANCING SOURCES Government : UA 3.00 million 10. LOAN APPROVAL DATE : May 2005 11. ESTIMATED START-UP DATE AND DURATION : January 2006 / 5 years 12. PROCUREMENT OF GOODS AND SERVICES: Under the project, goods, works and services will be procured in accordance with the rules of procedure of the Fund and the following conditions: Goods: International competitive bidding for biomedical furniture and equipment for the 2 CHR, 2 CMA, 31 CSPS and 4 screening centres. National competitive bidding for all other furniture, equipment, computer and office automation equipment, vehicles, insecticide treated bednets (ITNs). Local shopping for PIU furniture and equipment, sensitization material, publication of information leaflets on maintenance and cancer as well as other regulatory documents. International competitive bidding for drugs and medical consumables. CAMEG-Burkina Faso s central buying office for essential and generic drugs will be responsible for the purchases. Works: Services : International competitive bidding for construction works on two Regional Hospitals (CHR) in Ouahigouya and Tenkodogo, two CMA in the Centre- East. National competitive bidding for the normalization / rehabilitation of 31 CSPS, the Ouahigouya SIEM, construction of four screening centres and the Tenkodogo SIEM. Limited shopping following announcements in local or regional newspapers for experts services (individual consultants) for studies and strategies on regulations concerning the ministry of health and short-term consultants of the PIU. Shortlisting for the recruitment of: (a) consulting firms to undertake architectural and engineering designs, supervision of construction/ rehabilitation works on health units and control of works; (b) a biomedical engineer; (c) a procurement expert at the PIU; and (d) auditing firms and accounting firms for the computerized administrative, accounting and financial management system.
iii Shopping for specialized training institutes in the West African region or abroad, for the training of medical specialists and other senior staff. Limited shopping following announcements at the national or regional level for the services of training firms and NGO/Associations to undertake all the other training/retraining and sensitization activities. Direct negotiation with training institutes (CREPA and CIFRA), the Faculty of Health Sciences and the Ouagadougou University Teaching Hospital for specialities existing in the country. Agreements will be signed with these institutes. Operation: The 4 (four) senior staff of the PRSS project unit will be reinstated by the Government. The logistics and administrative assistant as well as the support staff of the PIU will be recruited locally according to the country s procedures. National shopping for the procurement of supplies and consumables. Agreements will be signed with Departments of the Ministry of Health and that of the Environment and Water for health personnel retraining and monitoring of project activities.
iv BURKINA FASO COMPARATIVE SOCIO-ECONOMIC INDICATORS Year Burkina Faso Africa Developing countries Developed countries Basic indicators Area ('000 Km²) 274 30 061 80 976 54 658 Total population (millions) 2003 12.4 811.6 4 940.3 1 193.9 Urban population (% of Total) 2001 19.8 38.0 40.4 76.0 Population density (per Km²) 2003 45.3 27.0 61.0 21.9 GNI per capita ( US$) 2002 250 671 1 250 25 890 Labour force participation - Total (%) 2002 47.0 43.3 Labour force participation Female (%) 2002 48.4 35.1 Gender-related development index value 2001 0.317 0.476 0.634 0.916 Human development index (rank among 177 countries) 2004 175 n.a. n.a. n.a. Population living below $ 1 a day (% of population) 1994 61.2 45.0 32.2 Demographic indicators Population growth rate Total (%) 2003 2.3 2.4 1.5 0.2 Population growth rate Urban (%) 2001 6.4 4.1 2.9 0.5 Population aged below 15 years (%) 2003 47.7 42.4 32.4 18.0 Population aged 65 years and above (%) 2003 3.8 3.3 5.1 14.3 Dependency ratio (%) 2001 107.6 85.5 61.1 48.3 Sex ratio (per 100 female) 2003 93.1 99.4 103.3 94.7 Female population of 15 to 49 years (% of total population) 2003 24.0 23.6 26.9 25.4 Life expectancy at birth Total (years) 2003 53.8 52.5 64.5 75.7 Life expectancy at birth Female (years) 2001 55.6 53.5 66.3 79.3 Crude birth rate (per 1000) 2003 46.1 37.3 23.4 10.9 Crude death rate per 1000) 2003 14.8 14.0 8.4 10.3 Infant mortality rate (per 1000) 2003 83.0 79.6 57.6 8.9 Child mortality rate(per 1000) 2003 184.0 116.3 79.8 10.2 Maternal mortality rate (per 100000) 2003 484 641 491 13 Total fertility rate (per woman) 2003 6.2 4.9 2.8 1.6 Women using contraception (%) 2003 15.8 40.0 56.0 70.0 Health and nutrition indicators Physicians (per 100000 people) 2003 3.3 36.7 78.0 287.0 Nurses (per 100000 people) 2003 26.9 105.8 98.0 782.0 Births attended by trained personnel (%) 2003 30.9 38.0 58.0 99.0 Access to safe water (% of population) 2000 78.0 60.4 72.0 100.0 Access to health services (% of population) 1999 90.0 61.7 80.0 100.0 Access to sanitation (% of population) 2003 35.2 60.5 44.0 100.0 Percentage of adults aged 15-49 living with HIV/AIDS 2001 7.5 5.7 Incidence of tuberculosis (per 100000) 2000 20.0 105.4 157.0 24.0 Child immunization against tuberculosis (%) 2003 86.3 63.5 82.0 93.0 Child immunization against measles (%) 2003 71.0 58.2 79.0 90.0 Underweight children (% of children under 5 years) 2003 42.2 25.9 31.0 Daily calorie supply per capita 2000 2 293 2 408 2 663 3 380 Per capita public spending on health (as a % of GDP) 2003 4.4 3.3 1.8 6.3 Education indicators Gross enrollment ratio (%) Primary school - Total 2003 42.3 80.7 100.7 102.3 Primary school - Female 2003 38.4 73.4 94.5 101.9 Secondary school - Total 2003 15.5 29.3 50.9 99.5 Secondary school - Female 2003 13.6 25.7 45.8 100.8 Primary school female teaching staff (% of total) 1998 24.4 40.9 51.0 82.0 Adult illiteracy rate - Total (%) 2003 77.7 37.7 26.6 1.2 Adult illiteracy rate Male (%) 2003 70.6 29.7 19.0 0.8 Adult illiteracy rate Female (%) 2003 84.8 46.8 34.2 1.6 % of GDP spent on education 1998 1.5 3.5 3.9 5.9 Environmental indicators Land use (arable land as % of total land area) 1999 12.4 6.0 9.9 11.6 Annual rate of deforestation (%) 1995 0.7 0.7 0.4-0.2 Annual rate of reforestation (%) 1990 8.0 4.0 Per capita CO2 emissions (metric tons) 2002 0.1 1.1 2.1 12.5 Per capita GNI (USD) Africa Population growth rate (%) Africa Life expectancy at birth (years) Africa Infant mortality rate (per 1000) Africa Source : Compiled by the Statistics Division from ADB Data bases, UNAIDS; World Bank Live Database and United Nations Population Division. Statistical Yearbook and EDS 2003 of the Ministry of Health of Burkina Faso. Notes : n.a. Not Applicable ;... Data not Available
v CURRENCIES AND MEASURES (February 2005) CURRENCIES Currency unit = CFA F UA 1 = CFA F 765.154 1 = CFA F 655.957 USD 1 = CFA F 503.229 MEASURES Metric system FISCAL YEAR From 1 January to 31 December LIST OF TABLES 2.1 Trend of budget of the Ministry of Health 7 2.2 Situation of ratios of personnel categories 19 4.1 Summary of estimated project cost by component 27 4.2 Summary of estimated project cost by category of expenditure 27 4.3 Summary of estimated project cost by financing source 27 4.4 Project cost by financing source and by component 28 4.5 Project cost by financing source and by category of expenditure 28 4.6 Expenditure schedule by component 28 4.7 Expenditure schedule by category of expenditure 28 4.8 Expenditure schedule by financing source 29 5.1 Schedule of activities 31 5.2 Schedule of supervision of activities 31 5.3 Procurement arrangements 32 5.4 Mid-term review monitoring indicators 37 LIST OF ANNEXES 1. Objectives and programmes of the National Health Development Plan 2. Millennium development goals of Burkina Faso 3. Contribution of donors 4. Appraisal report preparation process 5. MAP of Burkina Faso Project areas 6. Summary of socio-environmental arrangements of the project 7. Summary of detailed costs of project 8. Provisional list of goods and services 9. List of annexes of project implementation manual 10. Project organization chart 11. Implementation schedule of project activities
vi LIST OF ACRONYMS AND ABBREVIATIONS ADB ADF AIDS ANC BCEAO BI CADSS CAMEG CHN CHR CHU CHW CIFRA CM CMA CNS COGES CSPS DAF DEP DES DGHSP DGIEM DGPML DGS DHMT DHPES DIS DL DLM DML DMPT DPM DRH DRS DSF HD HIV HU IEC MEDEV EGD MFB MPA MOH NGO NHP African Development Bank African Development Fund Acquired Immuno-Deficiency Syndrome Antenatal consultation Central Bank of West African States Bamako Initiative Health System decentralization support Unit Central Buying Office for generic drugs and medical consumables National Hospital Regional Hospital University Teaching Hospital Community Health Worker International Action Research Training Centre Medical Centre Medical Centre with Surgical Unit National Health Council Management Committee Health and Social Welfare Centre Department of Administration and Finance Department of Studies and Planning Department of Health Facilities Directorate General for Hospitals and supervision of the private sector Directorate General for Facilities, Equipment and Maintenance Directorate General for Pharmacy, Drugs and Laboratories Directorate General for Health District Health Management Team Department of Public Hygiene and Education for Health Department of Health Facilities Department of Laboratories Disease Control Department Department of Maintenance and Logistics Department of Medicine and Traditional Pharmacopoeia Department of Pharmacy and Drugs Department of Human Resources Regional Directorate of Health Department of Family Health Health District Human Immunodeficiency Virus. Health Unit Information, Education, Communication Ministry of the Economy and Development Essential generic drugs Ministry of Finance and the Budget Minimum Package of Activities Ministry of Health Non-Governmental Organization National Health Policy
vii PADS PMU PLWHA PMTCT PNDS PRSS SIEM SM STD STI UA UNAIDS UNDP UNICEF WFP WHO Health Development Support Programme Project Management Unit People Living With HIV/AIDS Prevention of Mother-to-Child Transmission National Health Development Plan Health Services Strengthening Project Infrastructure, Equipment and Maintenance Services Safe Motherhood Sexually Transmitted Disease Sexually Transmitted Infection Unit of Account United Nations Organization for AIDS Control United Nations Development Programme United Nations International Children s Emergency Fund World Food Programme World Health Organization
viii BURKINA FASO HEALTH CARE DEVELOPMENT SUPPORT PROJECT - CENTRE-EAST AND NORTH REGIONS Project Logical Framework (Loan) By: R. Y. Coffi and two consultants Narrative summary Objectively Verifiable Indicators Means of verification Important assumptions By 2010: 1.1 Reduce mortality rate by 50% (14.8 in 2003). Sector goal Contribute to improved health status and well-being of Burkinabe people by achieving the health-related millennium development goals. Project objectives 1. Improve access to, as well as quality and utilization of health services in the Centre-East and North health regions. 1.2 Reduce infant mortality rate by 50% (83 in 2003). 1.3 Reduce maternal mortality by 50% (484 per 100 000 in 2003). 1.1 Increase in utilization of health services from 32.49% in 2003 to 37.7% in 2008 and 40.31% by 2010. 1.2 Increase in health services attendance rate from 34.46% in 2003 to 44.8% in 2008 and 50% in 2010 in the Centre-East, and from 24.47% in 2003 to 35% in 2008 and 40% in 2010 in the North. 1.3 Increase in contraception prevalence from 12.70% in 2003 to about 17.5% in 2008 and 20% in 2010 in the North and from 11.15% in 2003 to about 15.7% in 2008 and 18% in 2010 in the Centre-East. 1.4 Increase in ante-natal consultation coverage from 51.23% in 2003 to about 68% in 2008 and 76.84% in 2010 in the North and from 82.03% in 2003 to about 88.8% in 2008 and 92.28% in the Centre-East by 2010. 1.5 Increase in attended delivery coverage from 39.48% in 2003 to about 46% in 2008 and 49.75% in 2010 in the North and from 45.71% in 2003 to about 53% and to 57.59% in the Centre-East by 2010. 1.6 Useful life of facilities and equipment increased by 20% in 2008 and 25% by 2010. 2. Disease control in the project area. 2.1 Reduction of mortality in the North from 36.62% (2003) to 30% in 2008 and 27.46% in 2010 and in the Centre-East from 43.30% in 2003 to 36% in 2008 and 32.55% in 2010. 2.2 Reduction of rate of malnourished children from 43.50% in 2003 to 36% in 2008 and 32.62% in 2010 in the North and from 52.20% in 2003 to 43% in 2008 and 39.15% in 2010 in the Centre-East. 2.3 Reduction of mother-to-child transmission of HIV (MTCT) from 46.1% in 2003 to 43% in 2008 and 41.4%, by 2010. (continuation of 2 nd objective) 2.4 Reduction of HIV prevalence rate from 2.7% in 2004 to about 2% in 2008 and 1.5% by 2010. 2.5 Reduction by 16% of malaria-related morbidity and mortality, and by 25% by 2010. 1.1.1 Surveys to review the poverty reduction strategy paper (PRSP). Demographic and health surveys (DHS) and annual statistics yearbook. 1.2.1 Idem. 1.1.1 Idem. 1.1.1 Statistics yearbook of the Ministry of Health. 1.2.1 Idem. 1.3.1 Idem. 1.4.1 Idem and activity reports of the PNDS monitoring Committee. 1.5.1 Supervision reports of ECD, CMA and hospitals. 1.6.1 Supervision reports of the DGIEM, Statistics yearbook of the Ministry of Health. 2.1.1 Supervision reports of ECD, CMA and hospitals. Reports of the PNDS monitoring committee, Demographic and health surveys. 2.2.1 Idem. 2.3.1 Activity reports of laboratories, screening centres supervision reports of ECD,CMA and hospitals. Demographic and health surveys. 2.4.1 Idem. 2.5.1 Statistics yearbook. 1.1.1.1 The State pursues its health policy. The State and other partners continue to finance and implement their activities under the PNDS. 1.2.1.1 Idem. Personnel is available in quality and quantity for the health units and the populations support the different programmes. 1.3.1.1 The populations support the different programmes. 1.4.1.1 The State posts qualified personnel to the health units. 1.5.1.1 Idem. 1.6.1.1 Personnel is available for the health units. Facilities and equipment are maintained. 2.1.1.1 The populations support national disease control programmes. 2.2.1.1 Idem. 2.3.1.1 The populations support sensitization campaigns. 2.4.1.1 Idem. Idem.
ix Narrative summary Objectively Verifiable Indicators Means of verification Important assumptions Outputs 1. Health units are constructed and / or rehabilitated, equipped, supplied with drugs and operational. 2. The provinces of health regions have screening centres. 3. Medical and paramedical personnel of health units are trained and the populations attend health services. 4. The maintenance system is strengthened and operational. Maintenance of facilities and equipment is carried out in the health units of the two regions. 5. Medicine and traditional pharmacopoeia are practised in a healthier environment. 6. The risk-sharing system is put in place in 9 health districts in the project area. Activities 1. Architectural and technical studies. Various studies. 2. Training / sensitization 3. Construction/Rehabilitation of health facilities 4. Procurement of furniture, drugs and equipment 5. Audit of project accounts 6. Monitoring / evaluation mission 7. Management / monitoring / evaluation of project. 1.1 2 CHR, 2 CMA, 31 CSPS built and/or rehabilitated, normalized and equipped in 2009 at the latest, of which 31 CSPS and 2 CHR and 2 CMA are 60% achieved in 2008. 1.2 The 35 health units and nine district distribution depots are supplied with essential and generic drugs by 2008. 2.1 Four HIV screening centres are created, equipped by 2009 of which 80% are completed in 2008. 2.2 Training of 100 advisers (at least 1/3 female) in HIV/AIDS management, and 18 physicians in ARVT by 2010, of whom 60 advisers and 10 physicians in 2008. 2.3 Sensitization and patient management in 9 health districts, 80% completed in 2008. 3.1 The medical (at least 1/3 female) and paramedical personnel of the project area is trained by 2010: doctors, nurses, midwives, mobile workers and community health workers, management committee members, 2/3 of them by 2008. The populations are sensitized to the diseases during project implementation. 4.1 The Centre-East SIEM is built, the North SIEM is rehabilitated and both are equipped by 2009. In 2008, the works are 80% completed. 5.1 600 traditional doctors (at 1/3 female) are trained in the production of traditional medicine in an appropriate setting, by 2009, of whom 400 in 2008. Two drug production units are acquired, 9 botanic gardens set up in 2008. 6.1 About 18000 persons join 400 new mutuals or other alternative health funding mechanisms by 2009; and 80 personnel of those structures are trained, including 9000 members, and 40 managers trained in 2008. Project cost by financing source (in million UA) ADF loan UA 19.00 million Government UA 2.52 million Total UA 21.52 million Project cost by category of expenditure (in thousand UA) Total Loan Govt Goods 6.76 6.56 0.20 Works 9.71 7.91 1.80 Services 1.75 1.75 0.00 Operating 3.30 2.78 0.52 Total 21.52 19.00 2.52 1.1.1 Reports of acceptance of works and delivery of equipment / furniture. 1.2.1 Reports of acceptance of drugs. Activity reports of the Project Management Unit and Bank s supervision reports. 2.1.1 Reports of acceptance of works and delivery of equipment / furniture. 2.2.1 Activity reports of the project management Unit and supervision report of the Bank. 2.3.1 Idem. 3.1.1 Activity reports of the project management Unit and supervision report of the Bank. 4.1.1 Reports of acceptance of works and delivery of equipment / furniture. 5.1.1 Activity reports of the project management Unit and supervision report of the Bank, and of the PNDS monitoring Committee. 1.1.1.1 The State and other partners continue to finance and implement activities under the PNDS. 1.2.1.1 Idem 2.1.1.1 The State and other partners continue to finance and implement activities under the PNDS. 2.2.1.1 The populations subscribe to the different programmes. 2.3.1.1 Idem. 3.1.1.1 Personnel available in quality and quantity for the health units. 4.1.1.1 Supervision and monitoring of works well carried out. Counterpart funds available on time. 5.1.1.1 Traditional and conventional doctors support the programmes. 6.1.1 Idem. 6.1.1.1 The populations subscribe to prior contribution. Bank s disbursement documents. Project treasury statements of account. Report of the project management unit. Audit and supervision reports. The State continues to finance and implement activities under the PNDS.
x BURKINA FASO HEALTH DEVELOPMENT SUPPORT PROJECT - CENTRE-EAST AND NORTH REGIONS Project Logical Framework (Grant) By: R. Y. Coffi and two consultants Narrative summary Objectively Verifiable Indicators Means of verification Important assumptions Sector goal By 2010: Contribute to improved health status and well-being of Burkinabe people by achieving the health-related millennium development goals. 1.1 Reduce mortality rate by 50% (14.8 in 2003). 1.2 Reduce infant mortality rate by 50% (83 in 2003). 1.1.1 Surveys to review the poverty reduction strategy paper (PRSP). Demographic and health surveys (DHS) and annual statistics yearbook. 1.2.1 Idem. 1.3 Reduce maternal mortality by 50% (484 per 100 000 in 2003). 1.3.2 Idem. Project objectives 1. Improve utilization of health services in the Centre-East and North health regions. 1.1 Increase in utilization of health services from 32.49% in 2003 to 37.7% in 2008 and 40.31% by 2010. 1.2 Increase in health services attendance rate from 34.46% in 2003 to 44.8% in 2008 and 50% in 2010 in the Centre-East, and from 24.47% in 2003 to 35% in 2008 and 40% in 2010 in the North. 1.3 Useful life of facilities and equipment increased by 20% in 2008 and 25% by 2010. 2. Disease control in the project area 2.1 Reduction of mortality in the North from 36.62% (2003) to 30% in 2008 and 27.46% in 2010 and in the Centre-East from 43.30% in 2003 to 36% in 2008 and 32.55% in 2010. 2.2 Reduction of rate of malnourished children from 43.50% in 2003 to 36% in 2008 and 32.62% in 2010 in the North and from 52.20% in 2003 to 43% in 2008 and 39.15% in 2010 in the Centre-East. 2.3 Reduction of mother-to-child transmission of HIV (MTCT) from 46.1% in 2003 to 43% in 2008 and 41.4%, by 2010. 2.4 Reduction of HIV prevalence rate from 2.7% in 2004 to about 2% in 2008 and 1.5% by 2010. 2.5 Reduction by 16% of malaria-related morbidity and mortality, and by 25% by 2010. 3. Strengthen health system management. 3.1 All the regulations of the departments in the Ministry of Health are drawn up by 2008. 3.2 Quarterly supervision activities carried out by all the departments of the Ministry by 2008. Outputs 1. The provinces of health regions provide counselling in screening centres. 2. Medical and paramedical personnel of health units are trained and the populations attend the health services. 1.1 Training of 100 advisers (at least 1/3 female) in HIV/AIDS management, and 18 physicians in ARVT by 2010, of whom 60 advisers and 10 physicians in 2008. 2.1 Medical (at least 1/3 female) and paramedical personnel is trained by 2010: 15 medical specialists, 40 doctors, 25 officers, 27 technicians, 106 ECD members; 2 water sanitation officers, 60 senior technicians, 160 hygiene workers, 80 trainers in disease and hygiene; of whom 2/3 1.1.1 Statistics yearbook of the Ministry of Health. 1.2.1 Idem. 1.3.1 Supervision reports of the DGIEM, Statistics yearbook of the Ministry of Health. 2.1.1 Supervision reports of ECD, CMA and hospitals. Reports of the PNDS monitoring committee, Demographic and health surveys. 2.2.1 Idem. 2.3.1 Activity reports of laboratories, screening centres supervision reports of ECD, CMA and hospitals. Demographic and health surveys. 2.4.1 Idem. 2.5.1 Statistics yearbook. 3.1.1 Activity report of PNDS monitoring committee. 3.2.1 Idem. 1.1.1 Activity reports of the project management Unit and supervision report of the Bank. 1.2.1 Activity reports of the Project Management Unit and supervision report of the Bank. 1.1.1.1 The State pursues its health policy. The State and other partners continue to finance and implement their activities under the PNDS. 1.2.1.1 Idem. Personnel is available in quality and quantity for the health units and the populations support the different programmes. 1.3.1.1 Personnel is available for the health units. Facilities and equipment are maintained. 2.1.1.1 The populations support national disease control programmes. 2.2.1.1 Idem. 2.3.1.1 The populations support sensitization campaigns. 2.4.1.1 Idem Idem 3.1.1.1 Ministry personnel is available and there is proper coordination of health activities at all levels. 3.2.1.1 Idem. 1.1.1.1 The populations support the different programmes.. 2.1.1.1 Personnel available in quality and quantity for the health units.
xi Narrative summary Objectively Verifiable Indicators Means of verification Important assumptions are trained in 2008. The populations are sensitized to all the programmes during the project. 3. Hospitals play their referral role. 3.1 The plans of action of 12 hospitals are drawn up, implemented and supervised from 2008. 4. The maintenance system is strengthened and operational. Maintenance of facilities and equipment is carried out in the health units of the two regions. 3.2 The rates of charges for services and drugs are available and implemented in hospitals by 2009. In 2008 the rates are prepared. 4.1 Maintenance personnel is trained: 3 engineers, 22 senior technicians and 27 maintenance technicians, and about 200 users, by 2008 and the total of 405 users in 2009. 4.2 Maintenance and servicing manuals are available in the health units by 2009. In 2008, all manuals are prepared. 3.1.1 Activity reports of the Project Management Unit and supervision report of the Bank. And of the PNDS monitoring Committee. 3.2.1 Idem. 4.1.1 Activity reports of the Project Management Unit and supervision report of the Bank. 4.2.1 Idem. 3.1.1.1 All hospital personnel subscribe to the programme. Partners financial contribution is maintained 3.2.1.1 Idem. 4.1.1.1 Personnel available in quality and quantity for the health units. 4.2.1.1 Idem. 5. Medicine and traditional pharmacopoeia are practised in a healthier environment. 5.1 The populations (about 1 million) are sensitized to traditional medicine in 2008. 5.1.1 Activity reports of the Project Management Unit and supervision report of the Bank. 5.1.1.1 Traditional and conventional doctors and the populations support the programmes. 6. The risk-sharing system is put in place in 9 health districts in the project area. 6.1 The populations (about 1 million) are sensitized throughout the project to health-related risk-sharing systems. 6.1.1 Idem. 6.1.1.1 The populations subscribe to prior contribution. 7. The Directorate General for pharmacy, drugs and laboratories is more operational and plays its role better. Activities 1. Various studies 2. Drafting of regulatory texts 3. Training / sensitization 4. Procurement of drugs and equipment 5. Monitoring and supervision missions. 7.1 The drug importation monitoring system is put in place in 2007. 7.2 The location map for pharmacies is drawn up by 2007. 7.3 The laboratory policy and regulatory framework are formulated, as well as all regulations, guides and posters on cancer available in CHR and CMA by 2008. 7.4 The outlines and guidelines on action plans of hospitals are drawn up by 2008. 7.5 Six pharmacists (at least 1/3 female) trained in legislation, quality assurance and public health by 2010, and training will be under way in 2008. Project cost by financing source (in million UA) ADF grant UA 6.00 million Government UA 0.48 million Total UA 6.48 million Project cost by category of expenditure (in thousand UA) Total Grant Govt Goods 0.21 0.11 0.10 Services 3.84 3.84 0.00 Operating 2.43 2.05 0.38 Total 6.48 6.00 0.48 7.1.1 Activity report of DGPML and of the PNDS monitoring committee. 7.2.1 Idem. 7.3.1 Idem. 7.4.1 Idem. 7.5.1 Idem. Bank s disbursement documents. Project treasury statements of account. Report of the project management unit. Audit and supervision reports. 7.1.1.1 All stakeholders (pharmacists, laboratories, etc.) subscribe to the activities. 7.2.1.1 Idem. 7.3.1.1 Idem. 7.4.1.1 Idem. 7.5.1.1 Idem. The State continues to finance and implement activities under the PNDS.
xii EXECUTIVE SUMMARY 1. Project Origin and History Burkina Faso is one of the poorest countries in the world, with a human development index of 0.302 (2004). Poverty affects nearly one half of the population (46%) and is exacerbated in the rural areas (52.3%).The health status is particularly marked by a high mortality and morbidity rate as well as a low rate of access to basic health care for financial, geographical and cultural reasons. This situation is worsened by inadequate staff in terms of quality and quantity. The infant mortality rate of 83 per thousand live births is due mainly to malnutrition and infectious diseases. Malaria represents one of the leading causes of morbidity (on average 600 000 cases per year according to UNICEF), and is endemic along with acute respiratory and diarrheal diseases. Maternal mortality (484 deaths per 100 000 live births) is due to the low rate of antenatal and obstetric consultation coverage. HIV infection is marked by its stabilisation and affects all segments of the population. Faced with this situation, the Burkinabe Government prepared a poverty reduction strategy paper in 2000 and in the same year revised its national health policy (NHP). This enabled the Ministry of Health to draw up, in collaboration with health sector, stakeholders and development partners, a national health development plan (PNDS) for the 2001-2010 period. To ensure monitoring of the implementation of the PNDS, a monitoring committee as well as a technical Secretariat have been put in place. The PNDS prioritizes the decentralization of the health system based on the health district model, disease control, promotion of maternal and child health, strengthening of health infrastructure coverage, human resource development, resource mobilization for health. For the implementation of the PNDS, the Government has approached its partners, including the African Development Bank, to which a request for the financing of this project was submitted. The project concerns the Centre-East and North health regions and is in line with the Government s health policy priorities, as well as the general objectives of the poverty reduction programme. 2. Purposes of the loan and the grant The ADF loan of UA 19.00 million and the ADF grant of UA 6 million respectively represent 67.86% and 21.43% of total project cost, and will be used to finance 100% of the cost in foreign exchange, that is UA 19.22 million and 65.83% of project cost in local currency, or UA 5.78 million. 3. Project objective The project s main objective is to contribute to improving the health status and well-being of the Burkinabe populations. The specific objectives of the project are as follows: (i) improve access to and quality utilization of health services in the North and Centre-East health regions; (ii) control diseases in the project area; and (iii) strengthen the health system management through the Ministry of Health.
xiii 4. Project description The project will cover two health regions, viz the Centre-East and North and comprises four components, namely: (i) improved access to quality health care, (ii) disease control, (iii) capacity building, (iv) project management. 5. Project cost The total cost of the project before taxes and duties is estimated at UA 28 million, of which UA 19.22 million (68.64%) in foreign exchange and UA 8.78 million (31.36%) in local currency. 6. Financing sources The project will be financed by the ADF (loan and grant) and the Burkinabe Government. The ADF loan, which stands at UA 19 million, will be used to partially finance components 1, 2 and 4. The ADF grant of UA 6 million will finance component 3 and part of component 2. The Government s counterpart funds of UA 3 million represent 10.71% of total project cost, and will finance part of the civil works, equipment and operation. 7. Project implementation The project will be managed and implemented by the Project Management Unit (PMU) placed under the authority of the Secretary-General of the Ministry of Health and will be located at Ouagadougou. 4 (four) senior staff of the on-going PRSS (Santé II) project in the Bobo- Dioulasso region, whose performance was satisfactory will be maintained and strengthened for this project. The personnel will comprise: a coordinator, an architect, a doctor/ training specialist, a procurement expert, an accountant, an administrative and logistics assistant, a secretary, three drivers, a messenger and two watchmen. 8. Conclusions and recommendations The project is in line with one of the main thrusts of the poverty reduction strategy paper and with the orientations of the health policy paper and the country s national health development plan. It seeks to strengthen the health system in two health regions, the Centre-East and North, through the strengthening of health districts and CHRs, and building the capacity of departments of the Ministry of Health. Owing to the population s inadequate financial resources and the use of traditional doctors services, support is provided to set up health mutuals and organize the production of traditional drugs by traditional doctors. Given that the two regions are in border areas, attention is given to HIV/AIDS control and endemic diseases such as malaria, and to improved hygiene and children s malnutrition. It is recommended that an ADF loan and an ADF grant not exceeding UA 19 million and UA 6 million respectively be extended to the Government of Burkina Faso, for the purpose of implementing the project as described in this report, subject to the conditions specified in the loan agreement.
1. ORIGIN AND HISTORY OF PROJECT 1 1.1 Burkina Faso s total population is estimated at 12 419 677 inhabitants (2003) with 3 502 340 adult women (28%) and 2 148 604 children aged 0 to 4 years (17.3%). Life expectancy at birth is 53.8 years. With a human development index of 0.302 in 2004 (World human development report), the country is ranked 175 th among 177. Poverty which affects nearly half of the population (46.4%) is exacerbated in rural areas (52.3% against 19.9% in urban areas). Population growth was 2.3% in 2003 and there is a resurgence of epidemics. The agriculture and livestock sectors employ 86% of the working population and alone provide 35% of the GDP, while the secondary sector represents 19%. With a per capita GDP of CFA F 182 000 ($ 303.3) and an annual growth rate of 4.90% in 2003, Burkina Faso faces a major challenge which is the eradication of poverty. The low level of education, particularly of girls (33.4%), poverty, malnutrition, limited access to drinking water and basic sanitation are conducive to the spread of diseases. 1.2 The health situation is marked in particular by high morbidity and mortality rates and low access to basic health care (35.2%) for financial, geographical, cultural and health system performance reasons. Malaria represents one of the leading causes of morbidity (an average of 600,000 cases per year according to UNICEF) and is endemic along with acute respiratory and diarrhoeal diseases. The high maternal and infant mortality rates as well as the AIDS pandemic remain critical. These high rates are generally observed among the population affected by malnutrition and where the management of children by health services and households is of poor quality. This health situation is exacerbated by personnel inadequacy in terms of quality and quantity and the epidemiological pattern dominated by communicable and non-communicable diseases. 1.3 Faced with this situation, the Burkina Faso Government prepared a poverty reduction strategy paper in 2000 and in the same year, revised its national health policy (NHP). This enabled the Ministry of Health (MOH) to draw up in 2001, a national health development plan (PNDS) for the period 2001-2010, which represents the operationalization of the NHP. The health policy is based on the strengthening of primary health care through the strategy known as the Bamako Initiative (BI) and it gives priority to the decentralization of the health system. The PNDS for its part has as its main objective to reduce morbidity and mortality among the population. To implement the PNDS, the Government approached all its partners and in 2004, submitted a request to the African Development Bank to finance the strengthening of the two health regions of the Centre-East and North. 1.4 The project was identified and prepared in November 2004 and this report follows an appraisal mission to Burkina Faso from 24 January to 9 February 2004. This project is in keeping with the general objectives of the Government s poverty reduction strategy paper which seeks, among others, access of the poor to basic social services. It is in line with the national health development plan through its objectives and programmes and is based on the plans of health districts (HDs). It is also in conformity with the Bank s Country Strategy Paper (CSP) for Burkina Faso (2002-2004) updated in June and which confirmed that the social sector continues to be one of the sectors with a concentration of Bank Group resources. The project will contribute to the attainment of certain millennium goals such as the reduction of infant mortality, improvement of maternal health and control of malaria and HIV/AIDS. Lastly, it will supplement health sector interventions of the Bank and other partners.
2. THE HEALTH SECTOR 2 2.1 Health status 2.1.1 The health status in Burkina Faso remains precarious in spite of the Government s efforts in the health domain, a health unit attendance rate rising from 27.11% in 2002 to 32.49% in 2003, and an improvement of certain indicators. The country has one of the highest fertility levels in the region with a total fertility index of 6.2 children, a birth rate of 46.1 per thousand and the overall mortality of 14.8 per thousand (2003). The epidemiological situation is marked by the predominance of communicable diseases, high mortality and morbidity. The infant mortality rate and the likelihood of death between 1 and 5 years are respectively 83 per thousand and 184 per thousand live births (2003, PHS), due mainly to malnutrition and infectious diseases. The maternal mortality rate is 484 per 100 000 live births (2003) and the main causes of death are bleeding, infections, placenta retentions and abortion complications. 2.1.2 Among women, there is an improvement of certain indicators according to the 2003 statistical yearbook. In fact, the national contraception prevalence rate of 15.85% has increased compared to 2002, the obstetric coverage (attended deliveries) recorded an increase of nearly 3% (39.90% in 2002) to reach 43.69% in 2003, the national ante-natal coverage increased from 54.08% in 2002 to 70.87% in 2003, and post-natal coverage recorded an increase from 18.64% in 2002 to 30.85% in 2003. Only the average number of antenatal consultations per pregnancy dropped considerably from 2.6 in 2002 to 1.94 in 2003. 2.1.3 The main reasons for consultations are common malaria (33.02 %) and acute malaria (6.46%), respiratory infections (17.17%), unclassified diseases owing to inaccurate diagnosis (9.76%), diarrhoeal diseases (8.63%) and skin diseases (7.78%). This precarious situation exposes the population to the appearance of potentially epidemic diseases such as cerebro-spinal meningitis, measles, cholera and yellow-fever. Non-communicable diseases, notably chronic diseases (e.g. cancer, diabetes and cardio-vascular diseases) are on the rise. There is also a high prevalence of malnutrition with 15.27% of children consulted showing weights 80% below the normal curve of reference. In fact, about 44.5% of Burkinabe children under 5 years of age show stunted growth and 42.2% are underweight. 2.1.4 While Burkina Faso was one of the West African countries most affected by the AIDS pandemic with 7.17% in 1997, it is agreed that HIV/AIDS which affects all segments of the population is stabilizing and there is a remarkable drop in new infections. In fact, prevalence has decreased from 4.2% in 2002 (statistics yearbook) to 2.7% in 2004 according to surveys conducted on sentinel sites. Prevalence is much higher in urban areas (3.6%) than in rural areas (1.3%) and in terms of regions, the rate ranges from 3.7% in the South-West region to 0.1% in the Sahel. Over the period 2002-2003, the prevalence rate was over 1% among pregnant women on the 5 sentinel sites in the country and the number of women living with AIDS is around 150,000. Highway drivers are the most affected and youth (15 to 40 years) mortality is essentially due to AIDS. The management of PLWHA through ARV treatment under the 3x5 initiative launched by WHO, and other initiatives has improved rising from 1.36% in 2002 to 2.5% in 2003, but is still below the set target of 35%. HIV/AIDS and malaria which remain major public health concerns contribute not only to mortality but also constitute an economic burden for households.
2.2 National health policy 3 2.2.1 The Government s objective is to eradicate extreme poverty by reducing the incidence of poverty from 45% to 30% by 2015 and increase life expectancy by at least ten years by reducing neonatal, infant and maternal mortality; improving access to drinking water and increasing the literacy rate. To achieve these objectives, the Burkinabe Government has prepared, with support from its partners, a poverty reduction strategy paper (PRSP) which is the reference framework for any development action and is based on 4 main thrusts: (i) promoting sustainable accelerated and equitable growth; (ii) ensuring access of the poor to basic social services; (iii) expanding employment and income-generating opportunities for the poorest; and (iv) promoting good governance. These objectives are also in line with the vision of the millennium development goals (MDGs). For over two decades, Burkina Faso has adopted primary health care as a health development strategy and in 1987 adhered to the Bamako Initiative with emphasis on women and children through the provision of essential drugs, cost recovery and community participation in management. 2.2.2 On the basis of the orientations of the National Health Policy, and in consultation with all stakeholders of the health sector, the Government formulated a National Health Development Plan (PNDS) covering a ten-year period (2001-2010) and which is being operationalized through three-year plans, the first of which covers the period 2003-2005. The PNDS backed by a mediumterm reform programme comprises three pro-poor measures, viz: (i) improve health indicators among the poor; (ii) extend the involvement of the neediest communities in decision-making on health; (iii) limit the financial burden of health expenses on poor household incomes. It gives priority to the decentralization of the health system based on the health district model, disease control, promotion of maternal and child health, strengthening of health facilities coverage, human resource development, resource mobilization for health. The PNDS has eight intermediate objectives with corresponding programmes which are detailed in Annex 1. These objectives are consistent with the second main thrust of the PRSP which is ensuring access of the poor to basic social services, and with those of the HIV/AIDS control strategy framework. They are also in line with the millennium development goals (MDGs) and with those of the New Partnership for Africa s Development (NEPAD) in the domain of health (cf. Annex 2). 2.2.3 A round-table conference on the financing of the PNDS, held in April 2003, brought together health sector representatives, civil society, development partners and other sectors, and permitted: (i) a national consensus on the vision of the sector-wide approach to health development which is a priority of the Burkinabe Government; (ii) a census of external financing estimates for the dual purpose of mobilizing the necessary resources and harmonizing PNDS implementation strategies. The sector-wide approach is defined as a mechanism between the Government and its development partners, permitting the coordination of the Ministry s programmes for greater effectiveness of the utilization of the sector s resources. The objective of the sector-wide approach is to enable the putting in place of a common and sustainable funding mechanism by all sector stakeholders in order to ensure rational management of the funds mobilized, strengthening of decentralized management and increased financing of the PNDS. To that end, all the stakeholders have undertaken to pursue collaboration for the joint implementation of the PNDS and the evaluation of its performance. For the administration of the PNDS implementation, the Government put in place a monitoring and evaluation framework with the creation in 2003 of a Monitoring Committee chaired by the Secretary-General for Health, as well as a permanent technical Secretariat. 2.2.4 Besides this policy, and in a bid to improve the effectiveness of social services as well as service quality, the Government is committed to undertaking actions and measures covering several aspects: (i) application of the new charges for essential generic drugs (EGD) and the publication of the standardised list of basic medical services in health centres, (ii) reduction of the cost of pediatric treatment and attended delivery with free antenatal care, vaccination services and
4 vitamin distribution, (iii) increase in the votes allocated, and (iv) posting of personnel to regions and districts, (v) normalization of uncompleted facilities from HIPC (Heavily indebted poor countries) funds, and (vi) the application of technical equipment standards for all levels of care. For the implementation of the PNDS, a mechanism for medium-term expenses (CMDT) for the health sector was put in place in 2004; the CMDT is based on the priorities of the PRSP and enables better control of mobilized resources. To that end, civil service reform will strengthen the implementation of public service decentralization and the transfer of budgetary allocations to regions and provinces. 2.3 Organization and functioning of the sector 2.3.1 Administratively, the Burkinabe health system comprises 3 (three) levels: (i) the central level with the Minister s Office and the Secretariat General to which are attached departments, technical services, national and regional hospitals, and most of the health projects; (ii) the intermediate level with 13 regional departments of health (DRS), whose role is to implement government policy at the regional level, support the district health teams (ECD) and control standards; (iii) the peripheral level, represented by provincial departments of health (DPS), comprises 55 health districts which are the most decentralized operational entities in the national health system. This decentralization has enabled an improvement of the functioning of the system and better involvement of persons responsible for health and population. 2.3.2 Concerning care, public care structures are organized in 3 (three) levels. The first level, comprising health districts, each administered by a district health team (ECD) has two sub-levels: the Health and Social Welfare Centre (CSPS), which is the basic structure of the system and the Medical Centre with a surgical unit (CMA) which serves as a referral structure for district health units. Administratively, these structures come under the intermediate and peripheral levels which are Regional Health Departments (DRS) and Provincial Health Departments. The ECD comprising at least four senior staff, carry out the management, planning and technical supervision of public and private health unit personnel and activities in remote areas, clinical care delivery, integration of cross-cutting programmes and health research. The CSPS which covers an average population of 10,000 inhabitants is charged with delivering a Minimum Package of Activities (MPA) which are basic health care, supply of essential and generic drugs, public health and support and management activities. In the villages, two community health workers (CHW) carry out information, education and communication (IEC) and First Aid activities within the communities. CSPS also have management committees (COGES), set up under the Bamako Initiative in order to involve the population in the management of peripheral health units; they are charged with managing health units, but their operationality is not always optimum. CMA cover a population of 150,000 to 200,000 inhabitants each and serve as referral hospitals for all district health units; they provide referral, medical consultation, surgical and laboratory services. There are isolated medical centres (CM), maternities and dispensaries operating and providing care without meeting national norms. For this first level, there were in all 1339 health units in 2003, broken down into 38 CMA, 33 CM, 1147 CSPS, 28 maternities and 93 dispensaries. 2.3.3 The second level, represented by the Regional Hospital (CHR) serves as a referral hospital for CMA, and administratively comes under the central level. Although focusing on access of the populations to primary health care, the health policy recognizes the increased role of hospitals given the level of technical support centres in modern medical patient management. Given their status as public administrative establishments, the CHR are autonomously managed. Their referral hospital role consists in providing diagnoses, care, teaching, training, research and prevention. As such, the CHR must be equipped to plan its activities in order to be able to play its role. Burkina Faso has 9 (nine) CHR distributed in 13 health regions. The Plateau central and Centre-South regions have no CHR as they are close to the University Teaching Hospital of Ouagadougou and other CHR.